Healthcare Provider Details

I. General information

NPI: 1669410783
Provider Name (Legal Business Name): SEAGROVE MEDICAL CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 N BROAD ST
SEAGROVE NC
27341-8613
US

IV. Provider business mailing address

614 N BROAD ST
SEAGROVE NC
27341-8613
US

V. Phone/Fax

Practice location:
  • Phone: 336-873-7248
  • Fax: 336-873-7238
Mailing address:
  • Phone: 336-873-7248
  • Fax: 336-873-7238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29458
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number63868
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number29458
License Number StateNC

VIII. Authorized Official

Name: DR. MANJEET KAUR ACHREJA
Title or Position: OWNER
Credential: M.D.
Phone: 336-873-7248